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Gynecology & Reproductive Health Research Article ISSN 2639-9342 Gynecology & Reproductive Health Premature Ovarian Insufficiency: Under-Diagnosis and Diagnostic Opportunities Professor Lukman Yusuf MD, PhD1* and Associate professor Shiferaw Negash MD2 *Correspondence: 1Department of Obstetrics and Gynecology, College of Health Professor Lukman Yusuf, Department of Obstetrics and Sciences, School of Medicine, Addis Ababa University. Gynecology, College of Health Sciences, School of Medicine, Addis Ababa University. 2Addis Ababa, Ethiopia. Received: 18 July 2020; Accepted: 07 August 2020 Citation: Yusuf L, Negash S. Premature Ovarian Insufficiency: Under-Diagnosis and Diagnostic Opportunities. Gynecol Reprod Health. 2020; 4(4): 1-9. ABSTRACT Background: Premature ovarian insufficiency (POI) is basically cessation of menses, irregular menstruation or reduced fertility before the age of 40 years. It occurs in about 1% of the women population although younger women are not immune. The ultimate pathophysiology centers on the depletion of follicles and/or loss of endocrine function of the ovaries. Most commonly, it is idiopathic but possibly could be secondary to iatrogenic factors or a multitude of clinical conditions. Unlike natural menopause or acute ovarian failure, pregnancy is possible. Objective: The study will provide valuable information in the prevalence, clinical presentations and counseling of patients regarding the management options for the affected individuals. Setting: A clinical setting in the Ob-Gyn specialty clinic. Methods: All prospective, consecutive patients attending Ob-Gyn clinical services with complaints of irregular menstrual bleeding including amenorrhea and those visiting us for preconception fertility counseling and infertility. The study was conducted during the period extending from January 1, 2020 to June 30, 2020. Variables considered included socio-demographic characteristics like age, religion, ethnicity, residence, socioeconomic status (educational achievement, family monthly income) along with their obstetric performance and menstrual history. Transvaginal ultrasonographic findings and laboratory tests, especially and more importantly of the fertility panel and Anti-Müllerian hormone (AMH) were determined and documented. The variables extrapolated ensured accuracy, avoided redundancy and maintained confidentiality. The data was entered, cleaned and analyzed using Epi-Info statistics software program. Descriptive statistics like mean and median for quantitative and proportion/percentage for qualitative variables were used, respectively. Level of significance was set at P-value <0.05. Inclusion and exclusion criteria were set so that only patients with established scenario of hypergonadotrophic hypogonadism and diminished ovarian reserve vis-à-vis the AMH were availed. Results: Out of a total of 5348 gynecological patients, 130 were diagnosed to have premature ovarian insufficiency giving a prevalence rate of 2.4%. Among the subjects with POI, three (2.3%) achieved spontaneous pregnancy with folic acid and vitamin D with calcium prenatal supplementation, despite guarded prognostication and suggestion for donor egg or embryo transfer and intent to liaise them to where it is routinely practiced. The mean age was 34.8+ SD4.8 with the range being between 21-39 years. Their clinical presentations in the order of frequency were predominantly secondary and primary infertility and oligo-amenorrhea of up to three months followed by sign and symptom complexes of postmenopausal syndrome. The diagnosis was ascertained by ovarian reserve testing with ultrasound, blood tests that encompassed AMH, FSH, LH, estrogen, progesterone, thyroid function tests, serum prolactin and serum vitamin D and calcium levels. Conclusion: The study provides us with mounting evidence supported by the laboratory results that premature ovarian insufficiency is not a rare phenomenon and cites similarities reinforcing the fact that it is relatively more common than we anticipate. The available diagnostic means in such a low resource setting comfortably enables the capturing of the patients timely and channeling them for proper and comprehensive management options as deemed necessary. Gynecol Reprod Health, 2020 Volume 4 | Issue 4 | 1 of 9 Keywords Hashimoto’s disease, Grave’s disease, hypoparathyroidism, Premature Ovarian Insufficiency (POI), Premature Ovarian Failure pernicious anemia, auto-immune hemolytic anemia, ITPP, Type (POF), AMH (Anti-Müllerian hormone), Ethiopia. I Diabetes Mellitus (DM), vitiligo, idiopathic Addison’s disease and myasthenia gravis, karyotyping vis-à-vis gonadal dysgenesis Abbreviations Turner’s and Fragile X syndrome as well as pelvic irradiation, AMH: Anti Müllerian hormone; ART: Assisted Reproductive excessive surgical removal or drilling of ovarian tissue (acute Techniques; FSH: Follicle Stimulating Hormone; HBsAg: ovarian failure), chemotherapy and immunosuppression. Other Hepatitis B Surface Antigen; HCV Antibody: Hepatitis C Virus incriminated factors include viral infections, tuberculosis, Antibody; HIV: Human Immuno-deficiency Virus; HRT: Hormone chemicals, toxins and cigarette smoking. A series of investigations Replacement Therapy; ITPP: Idiopathic Thrombocytopenic commensurate with the management plan need to relate or Purpura; IUI:Intra Uterine Insemination; IUTPI/DIPI/FSP: correspond with the causal factors [7-9]. Intrauterine Tuboperitoneal Insemination; Direct Intraperitoneal Insemination; Fallopian tube Specialist Perfusion Program; IVF- The treatment options comprise of high doses of ethinylestradiol ET: In-Vitro Fertilization and Embryo Transfer; LH: Luteinizing (EE) for breast development, pubertal growth and sexual maturity, hormone; PCOS: Polycystic Ovarian Syndrome; POF: Premature mental, physical and social support in the very young. Prevention ovarian failure; POI: Premature Ovarian Insufficiency; RPR: Rapid of osteoporosis and cardiovascular diseases and promotion of Plasma Reagin; TPHA: Treponema Pallidum Haemagglutination sound sexual health and provision of treatment options like donor Antigen; TFT: Thyroid Function Test; VDRL: Venereal Disease egg with IVF and adoption are in the order of management plan. Research Laboratory. The administration of DHEA (Diethylepiandrosterone) increases a spontaneously conceived pregnancies, decrease spontaneous Introduction miscarriage rates and improve IVF success rates in women with Premature ovarian insufficiency (POI) entails a conundrum POI. When considering options like IVF, IUI, IUTPI/DIPI/FSP or of semantic issues for an entity expressing overlapping natural conception, one ought to exercise caution for fear of aortic pathophysiologic changes with similar clinical signs and symptoms rupture in Turner’s syndrome patients during pregnancy. Advanced but implying differences in the physical, mental and social well management choices include ovarian tissue cryopreservation in being of the individual. It was first described as POI by Fuller prepubertal individuals at risk, fragmenting of ovaries with Akt Albright in 1942 [1,2]. The connotation of premature menopause/ stimulators and autografting and hormonal therapy, and treatment premature precoce (praecox) if defined with low estrogen levels and with estradiol skin patch or vaginal ring by-passing the first pass higher values of FSH in the menopausal range and with the ultimate effect on the liver and medroxyprogesterone acetate per day for cessation of menses for over a year is quite troubling to the client and days one through 12 of each calendar month [10]. family as opposed to premature ovarian insufficiency which may be expressed with intermittent resumption of function, occasional More important in the management is counseling of patients and menstrual periods and pregnancy achievements. Primary ovarian families regarding their future fertility, risk of comorbidities, and failure with no menarche is invariably and strongly associated potential for genetic inheritance. Psychological counseling for with gonadal dysgenesis or X-chromosome anomalies. Premature the impaired self esteem, emotional distress and HRT for sexual ovarian insufficiency (POI) and decreased ovarian reserve tend to health and prevention of osteoporosis and cardiovascular diseases be reconciliatory than premature ovarian failure (WHO III) which ought to be part of the order of treatment. Furthermore, annual denotes an irreversible hypergonadotrophic/hypogonadism state general checkup for comorbidities and genetic inheritance should or the aforementioned terminologies that do not imply permanent be part of the future plan [11,12]. ovarian failure bearing in mind that pregnancies can spontaneously occur in 5 to 10% of such a population [2-4]. The prevalence of premature ovarian insufficiency is far more beyond case presentations [13] and deserves comprehensive Hence, premature ovarian insufficiency (POI) is the loss or analysis and documentation. Furthermore, an Ethiopian study depletion of function (diminished ovarian reserve), dysfunction on prevalence and severity of symptoms on peri, menopause and of the ovaries or loss of eggs resulting in variable estrogen post menopause was conducted on age range of 30-49 which is and FSH levels with marked fluctuation of menstrual patterns also inclusive of the very young without delineation from POI characteristically before the age of 40 years but surely after [14]. Therefore, the study highlights the existence of limited data, menarche. It tends to occur in about 1% of the women population appreciates
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